Which factors affect the choice of the inhaler in chronic obstructive respiratory diseases?

Abstract

a b s t r a c tInhalation is the preferred route of drug administration in chronic respiratory diseases because it optimises delivery of the active compounds to the targeted site and minimises side effects from systemic distribution. The choice of a device should be made after careful evaluation of the patient's clinical condition (degree of airway obstruction, comorbidities), as well as their ability to coordinate the inhalation manoeuvre and to generate sufficient inspiratory flow. These patient factors must be aligned with the specific advantages and limitations of each inhaler when making this important choice. Finally, adherence to treatment is not the responsibility of the patient alone, but should be shared also by clinicians. Clinicians have access to a wide selection of pressurised metered dose inhalers (pMDIs) and dry powder inhalers (DPIs) that can be used effectively when matched to the needs of individual patients; this should be perceived as an opportunity rather than a limitation.

Real-world asthma management with inhaler devices in Switzerland—results of the asthma survey

“…It should be remembered that "the ideal inhaler does not exist in real life" (34). An ERS/ISAM consensus statement provided clear guidance for choosing the most appropriate aerosol delivery device based on a patient's actuationinhalation coordination skills and level of inspiratory flow, among other clinical conditions (22,34).…”

“…An ERS/ISAM consensus statement provided clear guidance for choosing the most appropriate aerosol delivery device based on a patient's actuationinhalation coordination skills and level of inspiratory flow, among other clinical conditions (22,34). The correct use of a pDMI requires adequate coordination between actuation of the device and inhalation (or the use of a spacer) which has been rendered obsolete with DPIs (3).…”

The evidence on tiotropium bromide in asthma: from the rationale to the bedside

“…Major risk factors related to future exacerbations are represented by a previous history of exacerbations, increased use of oral corticosteroids and rescue medications, obesity, worse lung function, poor adherence to inhaled therapy, low Asthma Control Questionnaire (ACQ-7) score, co-morbid diseases, chronic sinusitis and cigarette smoke (Table 1) [3, 31–43]. Despite poor inhaler technique has been demonstrated to be related to worse asthma control [44, 45], most of the analyses designed to evaluate risk factors predictive of future exacerbations did not include it in the regressions [37]. The definition of full control in international guidelines includes the use of reliever medication less than twice a week, having no limitation in daily life activities, normal lung function and absence of nocturnal symptoms [3].…”

The importance of inhaler devices in the treatment of COPD

“…In fact, particles <2 micron deposit in the central airways but also deeper into the acinar compartment, while particles >5 micron tend to deposit proximally in the central airways or the oropharynx, where they produce no clinical effect and give rise to the potential for the drug to be swallowed and contribute to oral bioavailability and adverse sideeffects through gastrointestinal absorption. Two indices commonly used to characterise the particle size distribution emitted from aerosols are: the mass median aerodynamic diameter (MMAD), which is the droplet size at which half of the mass of the aerosol is contained in smaller droplets and half in larger droplets [31], and the fine particle fraction (FPF), meaning the proportion of particles <5 microns in diameter [32]. Both these indices can affect not only the total amount of drug reaching the lungs (total lung deposition), but also the amount of drug that is distributed between the central and distal lung regions.…”